28 December 2008

Went skiing with Gili and Bunnie the Younger, who had never been on skis before. She did very well, with a brief lesson and even venturing onto the Daisy lift. However, there was the obligate Epic Crash, when her speed got out of control and she plowed into a snowbank and had to be dug out. Much fun was had. Hope you all are having a nice break.

25 December 2008

The grandparents, paternal aunts, and uncle Gili got in yesterday. There are 22 inches of snow on our back deck. It's STILL COMING DOWN, heavily. There are huge tree limbs down all over. No vehicles can get in or out, not even the jacked-up 4x4. We are on generator power, but the internet is working. I got "Clone Wars Lightsaber duel" for the Wii. We are well stocked with Celebration Ale and Christmas cookies. I ask you: could this possibly be the BEST CHRISTMAS EVER?

22 December 2008

I'm working the early shift here in the ER today, and because of the historically bad weather here, I left really early for work. The commute was scary, but the streets were empty of traffic, and I arrived at 5:30 AM for my six o'clock shift. As I exited the parking garage, I noticed a man in work clothes shoveling off the walkway to the hospital. I was fiddling with my cell phone (actually texting the wife to let her know I made it OK) so I didn't pay him any mind. I was surprised when he greeted me by name, and more surprised when I looked at him more closely and realized it was the CEO of the hospital.

Shoveling snow.

At 5:30 AM.

In the garage.

The CEO.

I was stunned. I made a little joke about how he's been reduced to pushing a shovel, and he replied with good cheer, "Well, somebody's got to do it, and half the staff wasn't able to make it in, what with the roads and all. The last thing I want is for an employee or patient to slip on their way in -- that's be all we need!" We chatted for a minute and parted ways. As I was finishing my text, I noticed him stop to greet a couple of nurses on their way in, and thank them for coming in to work today.

Now that's leadership. He could have rolled in at eight and gotten a status report from the managers. He could have noticed the snow and called security (or whomever) to go shovel it. But here he was, in the dark and freezing cold, doing the job that needed to be done, and not coincidentally setting the example and the tone for the rest of the staff during a difficult time. I've worked with some less-than-stellar leadership in my time, and it's a painful thing. Having good leaders is absolutely critical.

Well done, Dave.O now, who will beholdThe royal captain of this ruin'd band Walking from watch to watch, from tent to tent,For forth he goes and visits all his host.Bids them good morrow with a modest smileAnd calls them brothers, friends and countrymen.With cheerful semblance and sweet majesty; That every wretch, pining and pale before,Beholding him, plucks comfort from his looks:A largess universal like the sunHis liberal eye doth give to every one,Thawing cold fear, that mean and gentle all, Behold, as may unworthiness define,A little touch of Harry in the night. -- Henry V, Act IV, Prologue

21 December 2008

Oh my this is fun (crazy, but fun). Seriously, we've had more snow than I can recall in my adult life. Eight inches in the last 24 hours, on top of what we've gotten the last few days. The kids are having a blast sledding, and I went sledding to work, sliding all over the freeway in a six thousand pound sled. (Sleds, as you may recall, have primitive steering and no brakes. That was consistent with my commute.)

Is it too much to ask that in the worst winter storm of the last decade, that people only come to the ER if they are actually sick? It was a busy shift, 24 patients in 8 hours, and maybe three of those people needed the ER. WTF? You came out in these conditions for the abdominal pain you've had for three months? A wound check? Seriously?

Happy has a nice post from a week ago about his experiences running in-house codes; it rung very true with me, as I too have run many many codes. The thing that made me laugh was his description about how his younger colleagues run to the codes. Like Happy, on principle, I never run to codes. The stroll there is a useful time to put myself in the right frame of mind to effectively run things, and I know by the location the code is at that there will be trained providers doing ACLS when I arrive (plus, as Happy alludes to, more than half the time the code is a false alarm). In fact, I affect a studied nonchalance about the whole thing -- it's no big deal, I'm such a badass, nothing can ruffle my feathers. It amuses me to do so, and I've been told (to my surprise) that my calmness in the chaos inspires confidence in my leadership. Call it an unintended benefit.

There was one code, though, which in retrospect could have been run a bit better.

This was a few years ago. I was standing in the nursing station chatting with one of my partners about something or another. It was one of those odd moments when we were the only ones in the station. The nurses were all off at their tasks, as were the techs -- very unusual, in that there are usually a dozen nurses and half a dozen techs on shift at any given time. And the unit clerk had stepped out for a moment. So there was just the two of us in the area when a woman rushed out from room seven and announced, "I think my dad's coding!" We reflexively looked at the monitor, which showed asystole, and we bolted into the room.

The patient was indeed unresponsive and not breathing. There was no pulse. We jumped right into action. My partner started chest compressions as I fumbled for the Ambu bag and hooked it up to oxygen. We were a little discombobulated as we got to business -- we are never the first responders and are not used to the role. I can't remember the last time I did CPR. I can ventilate a patient in my sleep, but usually the RT fetches and hooks up the equipment and just hands it to me. So it was with a sense of accomplishment and pride that, after a short time, we met one another's eyes and knew we had the important bases covered. I was bagging, and he was doing great CPR. Not too bad for a couple of docs, right?

There's a moment in the classic Monty Python "The Miracle of Birth" sketch when the doctors look at one another and say "something's missing -- what could it be?" and then simultaneously realize: "Patient!" We had one of those moments as we both thought "what's next... need to intubate -- where's my tube? And someone should be giving meds, and hey, who's going to do that if I'm bagging and you're doing CPR? Hey! Where are all the nurses?"

"We should get some help," my partner weakly offered. There was a security guard standing slack-jawed in the doorway. "Call a code!" we told him, but he was overwhlemed and just stood there. No help. We were stuck. I couldn't stop bagging and he couldn't stop CPR. What were we to do? I remembered the "code blue" button on the wall, and stabbed at it. A minute later, the overhead announcement went out: "Code Blue, ER, room seven." The reinforcements came pouring in moments later, and boy were they surprised to find the two of us there trying to resuscitate a patient all on our own!

They got to work right quick and we soon had him intubated and with a pulse. Honestly, I don't know how long our little "delay" was -- probably a minute or two. It felt like forever. Afterward, we all had a good laugh at our expense. Happy put it well: Without a team there. Without a crash cart. I am but a bystander. And we got a vivid reminder why in CPR class they teach you that the first thing you do in an arrest is call for help.

There's some validity to this argument -- limited validity, I must emphasize. There's certainly a role for mid-level providers (MLPs) in both primary care and in the ER. We utilize PAs (which are comparable to NPs) to great effect in our fast track, where they work within a defined scope of practice and with a subset of patients who are unlikely to have a complex or dangerous condition. Properly trained, they are cost-effective and valuable members of our group. What they are not is this: physicians. No disrespect, but they are mid-level providers; this implies that there exists a level of sophistication and quality of care somewhere between that provided by a doctor and a nurse. That's consistent with my experience. Their academic background is not as strong as that which physicians go through, and the selection process is less rigorous. The duration and intensity of their training is less, and due to their practice environments, the breadth and depth of their experience is lesser.

Again, no disrespect -- I employ a number of fantastic PAs that I would allow to care for my children. But they are not doctors. Girlvet pointed out that 90% of EM could be carried out by NPs. Perhaps. I'd put the fraction a bit lower, but whatever. If you are one of the 10% who needed something more, and all you get is an NP, you're screwed. (Note: that 10% would still be 10,000 patients annually in my ER.) And it's not easy to figure out in advance who the one in ten is who will need the doc.

While some primary care can be performed by a MLP, There was one comment at Ezra's piece that "primary care providers rarely treat anyone that has anything (really) wrong with them. by that i mean anything that wouldn't go away on its own given enough time." Oy. I suppose that things like diabetes and hypertension will go away on their own (just like "All bleeding stops... eventually."), but the management of chronic diseases is fantastically complex and not something that a simpleton with an algorithm can successfully pull off. I think people really do have no clue what it is that PCP's do. It's maybe not as immediately gratifying as Emergency Medicine, but it ain't easy. Some of it -- wellness care and some acute care -- certainly can be performed by MLPs, so long as they have access to a doc for the unexpected and complex issues that invariably do arise.

As for the general assumption that adequate NPs and PAs exist and could be convinced to provide primary care, I agree with Kevin that this is unlikely. There aren't 40,000 unemployed NPs hanging out waiting for primary care jobs, and even if there were, there are better opportunities to be found elsewhere for them. I know what we pay, and I know what some local surgeons pay their MLPs. Suffice it to say that these guys make more than most pediatricians or family practitioners. Shameful, but that's the market. Why on earth would they volunteer to take a (substantial) pay cut to do the job of primary care?

Finally, Ezra argues, that "I'm not aware of any consensus showing worse outcomes when patients see nurse practitioners." Sure. That'd be one hell of a study to do, particularly difficult in light of the fact that most patients change PCPs every year or two and that the relevant "outcomes" differences are undefined and probably undefinable (see the debate over how to define quality). Seriously, you're implying that we should assume that docs and MLPs are equivalent, absent evidence to the contrary? That's a stretch which absolutely defies common sense as well as my experience. If that were the case, indeed, it would not make sense to increase the pay of PCP's, but to cut it, as the job is too easy for a doctor.

No, Ezra is on the right track in the first part of his piece, in which he argues that the compensation system should be rejiggered to incentivize graduating doctors to enter primary care, and possibly to mitigate the cost of medical eduation for those entering primary care. I am sure that PAs and NPs will continue to play a role, possibly a growing role, in the provision of primary care. It is, however, highly unrealistic to expect that physicians can or should be displaced as the chief providers of primary care in the future.

18 December 2008

Not to join the ranks of the colleague-bashers, but one thing that has bugged me since we got a internal medicine hospitalist program is that "direct admits" seem to have become a thing of the past. It used to be that if an internist had a patient in their office who clearly needed admission, they called admitting, gave orders, and the patient went directly to the floor. Nowadays, they have to call the hospitalists, and they usually ask that the patient go to the ER for assessment prior to admission. They argue that the workups are easier to do in the ER, and that some of the patients can go home after some intensive ER therapy, and we bristle at the added cost, the added burden to the busy ER, and the feeling of getting dumped on.

It's a little annoying, but what the hell, it's not like we can prevent it so I suck it up with good grace.

So today I got a call from a clinic doc who I have known and respected for a long time. He was very apologetic: he had a lady with obvious pyelo who was clearly sick enough to be admitted and he had to send her to the ER. The hospitalists had been called, and did not want to take her without an ER evaluation. He made it clear from his tone that he thought they were being weak and that this was another waste of time and effort. As I always do, I thanked him with good cheer and said we'd be happy to see her.

Well, when she showed up, there turned out to be more to the tale. She was septic as hell, with a blood pressure in the seventies. Her lactate was four and a half, and she turned out to have not pyelo but a right sided diverticular abscess. (I was proud of figuring that out, since it really did seem like pyelo.) She went not to the floor, but to interventional radiology and then to the ICU. A little while later I happened to speak with the hospitalist, who inquired if the patient had ever showed up. I related the tale, and he laughed and said, "Yeah, it sounded funny. That's why I had them go to the ER first." I hate to admit it, but he had a point.

Damn it.Note: Yes, I realize that there are probably a lot of direct admits that I never know about because they do bypass the ER. I'm not going to let some tawdry facts get in the way of a good rant.

17 December 2008

It's a weird thing that pretty frequently I see a patient for abdominal pain, and he or she will tell me that they even "tried vomiting" but it didn't help.

Seriously.

I don't know why, but it seems to be a widespread belief that vomiting will make you feel better. I hate vomiting. It leaves me covered in sweat, shaking, and weak as a kitten. I avoid it at all costs. And people do this deliberately. Amazing.

16 December 2008

Just for the record, I have to agree with Dr Rob that the anti-primary care screed over at Emergency Medicine News is, well, it's just embarrassing. I've put out my fair share of poorly-thought-out or inflammatory posts, so I can sympathize. But Dr. Glauser is not just wrong, he's cringe-inducing in his ranting. As they say on the interwebs: Epic Fail.

Rob makes a couple of nice observations:

There are some really angry doctors out there. Any time people are fighting over their share of money, you see their worst.

There are many physicians out there who don’t respect primary care. They seem to think that we do our job because we couldn’t get into “better” specialties.

13 December 2008

Helmets are mandatory where I live now, but every once in a while I go back to Chicago, and I see someone ride a motorcycle down the street sans helmet. It's always startling to me, and shocking that nobody else takes note of it. It's as if you were at a nice cocktail party and a naked man walked in, poured himself a drink, and left, without any of the other partygoers batting an eyelash. Of course, why would they? It's a perfectly common sight, to them. But I can't get over the "Hey, that dude's not wearing a helmet!" reaction. My friends all think I'm a rube, now.

I learned the value of a helmet firsthand a couple of years ago. I was skiing in icy conditions, in the late afternoon on a cloudy day. The light was really flat and I did not see the six-foot drop-off until I was well into mid-air. In fact, I never did see the drop-off, but I inferred its existence from the absence of snow under my skis. I was going pretty fast and hit hard on my back, with my head whiplashing back onto the hardpacked ice. Due to the helmet, I was merely stunned; I am convinced that I was in subdural territory had my skull been without protection. I've always been conscientious about wearing the brain-bucket; since that day I am downright fanatical. And since one of our ERs is right down the hill from the pass, every skier and boarded who comes in without one gets that lecture.

On that note, they picked up fifteen inches of snow last night and should be opening up soon. I can't wait!

If you're wanting a quilt with a bit more social value, though, you can't do any better than bidding on this quilt:It features the beloved Zippy the Lobster, and the proceeds go to the Childhood Brain Tumor Foundation. Instructions to bid can be found here. It may not have the Apple logo on it, but it is imbued with several extra insulating layers of good karma which are guaranteed to make you feel all warm and fuzzy when you wrap it around your shoulders. The auction ends Dec 15, so you'd better hurry!

First-born Son recently learned "My Country, 'tis of Thee," in kindergarten, and it is his favorite song. He sings it all the time, as a high-pitched, atonal dirge, with most of the words wrong, over and over.

10 December 2008

In case you weren't paying attention, ACEP released its national report card on the State of Emergency Care in the US today. The result looks like a lot of my high school report cards -- a lot of C's, a couple of D+'s, and a B here or there. (Insert joke about the state of the educational system here -- we're a C- nation.)

My state did surprisingly well in Quality/Patient Safety as well as Public Health and Injury Prevention. However, we rated an F in access to care, which it completely unsurprising. We rank absolutely last in the number of inpatient beds, and in the number of psychiatric beds, and also in the number of ICU beds. We also suffer from a shortage of primary care physicians, which exacerbates the fact that our state has half the number of ERs as the national average. Explains things like this, I guess.

Our state also did poorly (D-) in the liability climate, which was interesting. We don't have caps, but our average award is less than average by a small amount. (It would be nice if premiums reflected this, which they most assuredly do not.)

I'll have some more on the national conclusions and recommendations later, when I'm not at work.

I recently saw a patient who was sent to the ER for treatment of an acute DVT. I was surprised that he was not already on warfarin because he had a history of multiple previous DVTs and even two pulmonary emboli, with no clear explanation as to why he had recurrent clots. He explained that his primary care doctor was opposed to warfarin and had put him on a "natural blood thinner," which was also good for his cholesterol. I looked this med up (I can't remember the name) and found some references which stated that this substance was essentially worthless for either of these indications. He was being treated by a local naturopath, he added, who had told him that the warfarin was damaging his kidneys and his liver. He seemed a bit skeptical of this, since he had been maintained on warfarin for many years without any side effects. I explained to him that he was going to need to go back on the coumadin (and low molecular weight heparin) for at least the next six months, and probably, given his history, for the rest of his life. He seemed quite content with this plan.

His wife expressed some concern about the quality of care her husband was getting from his doctor. He was rather medically complex, with blood pressure, heart and vascular disease, diabetes, and other chronic medical conditions, and I was frankly surprised that a naturopath would care for such a complex patient. They both wondered whether he would be better off going to an internal medicine doctor, and his wife openly asked if I trusted naturopaths. She hoped that I could set him up with an internist to manage the initiation of coumadin; the patient himself seemed amenable to this, and looked to me for a recommendation.

Tough one. I hate to steer someone away from their doctor; it feels unprofessional or discourteous. But it was the patient and his wife who had opened the door...

So what do you think I should have done in this situation? I have the standard MD bias that naturopaths are credulous purveyors of woo, which in this case was supported by the fact that his hypercoagulable state was being treated with a placebo. In addition, this gentleman was quite genuinely complex from a medical management point of view, and I felt he would probably menefit from an internist's expertise. On the other hand, I am completely ignorant about the training and scope of practice of NDs, and a review of the records showed that a reasonably competent work-up had been done for hypercoaguability (Factor V, Homocysteine, anticardiolipin, though not a complete work-up), and that he had been seen by appropriate medical specialists when needed. Calls to the ND's answering service were not returned.

So how would you handle this? Would you send him back to the ND? Would you set him up with an appointment at the local internal medicine clinic? Is there a compromise position here?

08 December 2008

1. Set up a large, well capitalized hedge fund. About $5B should do it.

2. The prospectus of the fund should note its purpose is to “Seek out profit opportunities via arbitraging inefficiencies in the markets and health care system of the United States.” Include standard “Socially Conscious” fund language in clauses such as Do well by doing good.

3. Launch the fund — and promptly max out your leverage. Today’s environment makes it difficult to go 50 to 1, but getting 10 or 20 to 1 should not be much problem.

4. Use the money to write Credit Default Swaps with a notational value of $3 trillion dollars. The premia on these CDS should be about 10-15% or so.

5. Rollover the cash premiums — about $350 billion dollars worth — into a national fund. Use it to buy health care insurance for all US citizens.

6. Declare that due to current credit conditions, your unfortunately must announce to your counter-parties that you will be defaulting on these CDS. Note that significant amounts of this paper are held by JP Morgan and Citi. Another trillion is held by China and Japan, with Sovereign Wealth Funds owning the rest.

This is as sad as anything else I have seen in a long time. A woman in her mid-thirties came in to my ER with a near-completion of a suicide attempt. Her husband reported to me that she had been diagnosed with bipolar disorder for a number of years, and had been doing extremely well on medications -- well enough to get married, start a career, and have a family.

Unfortunately, their family had hit some hard times and both she and her husband were temporarily out of work. He found a new job, but during the transition their health insurance lapsed. Her psychiatric medications, all brand-name, were terribly expensive, and money was tight around the house. So they made the decision that she would go off her meds, just for the couple of months until his new insurance kicked in. The risk seemed pretty small, since she had been doing so well for a very long time.

The first few weeks off the meds were not too bad, though she was moody and irritable. They had a fight a couple of weeks later, and then another. But other than that, there didn't seem to be any indication that she was slipping off the cliff. Then, after a fairly minor disagreement with her husband, she went and did something impulsive, with no warning.

And that's when she came in to see me.

After a short course in the hospital, she succumbed to her self-inflicted injury.

The sad thing, other than the terrible human tragedy, was how unnecessary this was. Why on earth did they think she could go off her meds? That was a bad decision on their part, but the consequence was an undeserved death sentence. Didn't they know they could apply for a free supply of meds from the manufacturers? Didn't they think of going to their church, or some other charity source for assistance? Couldn't they have gone back to her mental health provider to see if a cheaper prescription was available for the short-term?

But they were not sophisticated, medically, and didn't think of these options. They were self-reliant, figured this was their problem and they would figure out a way to get through it. They made the wrong choice, and now she is dead, and their children have no mother.

This is what makes me nuts about this whole universal health insurance debate. You have the folks on the right who deny reality and claim that those who are uninsured "choose" to be uninsured and that we shouldn't force people to pay for coverage they don't need or want. The conservative ideologues who theorize that the problem is that Americans have too much health insurance and what we really need is to let patients make rational decisions about where to allocate their health care dollars. The traditionalists who like their employer-funded health care plans who are afraid of severing the link between employment and health insurance.

This case, in a nutshell: a real, actual person whose life was lost due to our insane patchwork health care system. This case is an example of why we need fundamental reform of our health care system. One life is just an anecdote, I know, but writ large, how many times does this happen annually among the 60+million who are uninsured at some time in any given year? What is the gross morbidity and mortality that our insurance system exacts from our society?

Employer-based health care is great, so long as you are stably employed. If you lose your job, your health is at risk. Or you face the devil's choice of paying the mortgage or paying for your meds (or COBRA coverage). While I understand the general resistance of Americans to part with the known and understood health care which their employer pays for, a system which ties employees to a job for the insurance, which burdens employers relative to their foreign competitors, and which has no realistic provision for the newly unemployed to retain health care is both callous and stupid, from a policy perspective.

Despite the rhetoric regarding "patient directed health care," the truth is that patients do not always make rational decisions. Patients will, not in all cases but with a knowable statistical likelihood, forgo needed care, spend money on the wrong priorities, and generally lack the knowledge base to decide how best to spend their health care dollars. (Even if there was price transparency, which there is not.) This is not to say that patients are incapable of making these decisions, but that the consequences of shifting this burden onto patients does have a direct human cost.

It is fairly clear that, with the incoming Obama administration, the consensus is building towards a fundamental restructuring of the health care funding system. The designation of HHS Secretary Daschle, in addition to the Baucus white paper and the Kennedy committee are clear signals that the Democrats are serious about moving forward. The labor movement has found their strange bedfellow in the small business association, and even the medical lobbies are cautiously in favor. There's a lot that can go wrong, and a lot of heavy lifting to be done to transform the rhetoric into reality. I can only hope that they are successful, and that they do it right.

There are a lot of people whose lives may depend on it, even if they do not know it. It's too late for one patient and her family. Their children are eight, five, and two years old.

06 December 2008

I came on at 7AM and the ER was going through its daily decompression routine. The night-time doc was just brain-dead exhausted and going through the motions in getting rid of his last few patients. There were a few stragglers from the overnight shift who had not yet been seen, and I jumped on them, full of caffeine and energy. A toothache. A laceration. Room 3-1 contained a very nice but weary mother whose six-year old son had a sore throat. It was obvious strep, and a quick prescription later, they were on their way. I felt kind of bad for them, since they had been waiting for three hours, but that's what happens when the night shift is backed up.

Then the new patients started showing up, and I just kept on moving through the tide. A headache. Vomiting. I went back into room 3-1 to see a teenage girl with an ankle injury and stopped short as I saw the same weary mother sitting there by the bedside. "You again?" I blurted out. I had a brief moment of panic -- had I forgotten to discharge them and had she been sitting here the whole time? No, there was a new patient -- the ankle injury (the boy with strep was there at the bedside, as well). The mother explained that no sooner had she gotten home than she had gotten a call from school that her daughter had fallen on the steps, so here she was, back again, in the very same room. She ventured a weak smile.

Her daughter had a nasty fracture-dislocation, which I reduced and splinted. Again, I sent them on their way with well wishes and an admonition not to come back again! What a terrible day for the poor woman. Well, at least they'll have a story to tell.

05 December 2008

I've got a slightly longer commute than I used to, and I've been getting slowly addicted to podcasts. I can't stand any radio with commercials or call-ins, and NPR has way too many shows about gardening or forgotten 1930s jazz icons to sustain my interest. Lately I've been listening to and enjoying, in no particular order:

I'm about two-thirds of the way through a night shift and it's driving me up the wall. I've seen sixteen patients at this point, and of them, three have been "legit" patients (a fractured humerus, a kidney stone, and an MI). The other thirteen have been completely bogus. Worse, of the sixteen, nine by my estimation were addicted to or dependent on narcotics (including the kidney stone: argh). This is just painful. No pun intended.

04 December 2008

No conversation in the ER that begins with "Hey, remember that guy from the other night?" is going to turn out well. It's an absolute law.

The case that the charge nurse was reminding me of was a young man whom I had admitted with a head injury. It was typical high-schooler foolishness: he was screwing around with his friends and managed to fall out of a moving car. The car was going pretty slowly when he exited the vehicle, maybe ten miles per hour, but he managed to hit hit head on the pavement on his way out. Concrete and asphalt are very unforgiving surfaces when they come into contact with a skull, and this case was no exception. He had a nondisplaced occipital skull fracture, and a tiny subdural hematoma.

Those injuries looked nonsurgical, but the bigger problem initially seemed to be the frontal lobe contrecoup contusion -- literally a bruise in the tissue of the brain. The frontal lobe of the brain is responsible for many of the higher functions, and the injury to this area causes a lot of functional impairment. In this case, the patient was showing signs of frontal release. He was agitated, confused, rambling incoherently, and (most disturbingly to his family) inappropriately hypersexual. He was, they reported, exceedingly well-mannered, ordinarily, and never even swore. But he was quite disinhibited by his injury.

His family was one of the nicest I have encountered in a long time. They really struck me by how great they were, even under substantial stress. They were warm and kind people, even taking time to thank all the nurses who cared for their son. I reassured them that his injuries, while serious, did not appear to be life-threatening. We had a long conversation about traumatic brain injuries and the potential complications and rehabilitation, and I felt that it really helped them get their heads around what had happened. They went up to the ICU, under the care of our neurosurgeon.

So it was with utter shock, five days later, that I heard the charge nurse finish her sentence: "You remember that guy the other night with the head injury? He just died upstairs!"

Apparently, his brain had swelled, and young people have tight heads -- not a lot of room in there for swelling. When the brain grows bigger, it displaces the cerebrospinal fluid from the skull, then can even cut off the blood flow as the pressures increase. A nuclear medicine scan had confirmed brain death.

It was terrible, but to me it was also incomprehensible. He had had a GCS of 14 when I took care of him, and just didn't have the hallmarks of someone at high risk for mortality. Should I have sent him to the regional trauma center? There was nothing really on initial presentation that implied he needed it. Other than getting a bolt -- an intracranial pressure monitor -- he never had developed lesion that could be addressed with surgery. Neurosurgery can be frustratingly futile, sometimes.

And I felt (and feel) terrible for his poor family. I bonded with them more than usual, and their suffering must be terrible. I went upstairs to the ICU after my shift, but they weren't around, and the transplant team was getting ready for harvest. The ICU nurses had a very grim satisfaction that it would be a "full harvest" -- all the organs were in great shape.

I don't really have a take-home point for this post. If I did, it might be: shitty things happen to nice people who don't deserve it. Or perhaps: this job will surprise you again and again, and you need to dispel that false sense of certitude when prognosticating. But whatever. Mostly, this was just a crappy case and I wanted to vent. Thanks for reading.

01 December 2008

Great. That's all we need. We're already screening for Domestic Violence, Depression, Fall risk, various and sundry immunizations, alcohol abuse and Jeebus-knows-what-else. Why not add one more critical social issue to the laundry list? The ER can be the one-stop shop for all epidemiologic screening! We'll do your cholesterol, your PSAs, your PAP smears, and colonoscopies on Tuesdays!

Don't come in for anything frivolous, though, like chest pain or a motor vehicle accident, because the primary and secondary surveys will have to wait until the triage nurse asks you if you have "ever felt unsafe or threatened in any of your personal relationships." Seriously, they have to ask everybody these questions. I always feel bad listening to the nurses as they have to go through the litany of screening questions which are completely unrelated to the serious issue which brought the patient to the ER.

So why not add HIV to the list?

The biggest reason, IMHO, is that it's not germane to our practice, and not relevant to the patient's presenting complaint (in 99% of cases). Furthermore, it would bog us down and worsen the delays in the waiting rooms as we complete the screenings. If a patient comes in for an ankle sprain or some such, they need to get blood drawn for an HIV test? That's gonna take 10-30 extra minutes (depending on phlebotomy's availability), not counting the detailed consents which most institutions perform before HIV testing. Then what's the turnaround time for the test to run? 30-60 minutes at best, I suspect (factoring in the sample transport time and lab processing time). This would be a minimal issue for patients with six-hour abdominal pain work-ups, but the large number of patients with simple or quick complaints would be slowed down. And the docs, already overburdened with a thousand other tasks and interruptions, would have the responsibility to counsel each and every patient on the meaning of their test (negative or positive), and that counseling is sure to provoke a conversation that eats into the time I have available for the rest of my patients.

This is not even considering the liability. If a test is misreported by the lab, or simply missed by the physician, or if the patient leaves prior to the result being communicated to them, this creates a terrible burden on the providers. And if a test is positive, and the patient does not get adequate counseling or follow-up, whose responsibility is that?

No, routine HIV screening should not be performed in the ER. It's not our job, we're too busy, and we don't want the extra liability. And I kinda wish that society and the government would stop pretending that the ER is the only (and universal) point of contact that Americans have with the health care system.

Buckeye Surgeon has an interesting post about an academic surgical/trauma program which, it seems, is trying to poach the good cases redefine trauma surgery as "Acute Care Surgery." In short, the Orlando program is making a (rather lame) argument that they should do not just all trauma, but all the acute surgical cases in the region, as "specialists" in acute care surgery.

I can't add much to Buckeye's commentary -- it's dead-on. This is a play for dollars and training cases, and completely unjustified from an economic, efficiency, and quality of care perspective. But there's another, tangentially related point here. Buckeye asks whether trauma surgery, as a specialty, is viable. In my humble opinion it is not, at least not on a large scale. As a niche it will persist as long as guns and motor vehicles do. What will happen, I predict, is that "Trauma surgery" ultimately will, in fact, transform itself into (or be replaced by) a new specialty of "Acute Care Surgery," which might be more simply described as "Surgical Hospitalists."

This specialty, rather than sucking cases from community centers to academic, will function somewhat the other way. The surgical hospitalists will metastasize to smaller institutions, instead of centralizing to the academic centers. The market makes a compelling case for surgical hospitalists in community facilities (on an efficiency basis), which will promote community hospitals retaining more surgical cases and transferring fewer cases to the Mecca.

Think of it this way: every ER call, every acute case, every in-hospital consult represents a time burden for the on-call surgeon. At academic hospitals, this burden is typically borne by the in-house residents, 24/7, so there is no real cost (other than to the limited sleep of the intern). If you are a community surgeon, trying to see patients in clinic, or operate on your scheduled cases, or get some sleep before a full day of clinic, this burden is rather more onerous. Cases get canceled, clinics get backed up, and you are tired and overwhelmed. Call is not easy for community-based surgeons, and the cost to their paying, elective cases, is significant. There is a compelling need for these doctors to want to end the "on-call" system.

Surgical hospitalists are the answer to their prayers. They handle the bogus (and unprofitable) trauma cases. They handle the ER and the consults. They free you up to focus on your own patients. And it's not a bad lifestyle either, for the hospitalsts. They work shifts, have a predictable schedule, get to operate a lot and generally get to do the "fun" surgical stuff. This is often most appealing to newer graduates, who are closer to their training and perhaps more comfortable with hospital-based medicince, complex cases, and

The economics of the case are the most challenging. A hospital would need a certain volume of acute cases to support a surgical hospitalist program. I've not done any research on the matter, but my back-of-the-envelope guess would be a 200-bed hospital with a 40,000-visit ER would be the smallest facility that could keep their surgeons busy. And who pays? As with internist hospitalists, they may not generate enough pro-fee revenue to cover a competive salary. Perhaps the facility itself might subsidize them, to keep the call schedule filled and to keep the community surgeons happy. Perhaps the community surgeons would see enough value in the efficiency to hire their own hospitalists. Or maybe each surgeon would take their turn in the barrel. There are a variety of models that could work for this program.

I should point out, in fairness, that our facility has had such a program in operation for a few years now -- maybe as many as four. I am not quite sure. It's been a huge success for all of us -- the ER, the internists, the clinic surgeons, and the surgical hospitalists (I mean, the acute care surgeons). If I need a surgical consult, they can be there right away, even at three AM. They come to see patients more, rather than just asking for a CT scan and a call-back. They are willing to admit more cases which could have been challenging dispositions, and they have service agreements with the internal medicine hospitalists for the overlapping cases (SBOs, gallstone pancreatitis, etc), so "dumping" on internal medicine never happens any more.

Better yet, it's vastly improved the relationship of our two departments. The in-house surgeons are in the ER enough that it's just part of their routine and they don't resent the calls, because they bring an attitude of "this is what I'm here for." The community surgeons still occasionally get calls from us, but more often during working hours and less often at 3AM, and thus they view us as less of a burden and more as valued colleagues.

I don't know for certain whether this model will catch on in the larger sense. Maybe surgical care is too fragmented into small competing practices. Maybe you need a really busy facility to support them. I think it's the future, though, and I know it's been an amazingly positive experiment for us.

23 November 2008

No, not the good kind, blowing stuff up and all that. The Washington Post takes a shot at the Five Myths about US healthcare. It's a nice start, for a traditional media source and a general audience. For health policy wonks and readers of med blogs, probably not too much new there.

I don't have time to fisk it in depth, but a couple of quick observations:

Myth One: America has the best health care in the world.This is basically a rehash of the OECD data showing the US lagging in outcomes such as life expectancy and infant mortality, while spending 50% more than our nearest comparison. While the OECD numbers have come in for a lot of criticism, and there's a lot more to the outcomes than the quality of the health care system, the authors make one point very well: the cost/expense of medical care does not correlate well with outcomes or quality. This is, in fact, an important point to make. Also, I like the fact that the Post is tackling the zombie myth that the US is the M*A*S*H 4077, the "Best Care Anywhere," since that perception is a significant impediment to reform.

Myth Three: We would save a lot if we could cut the administrative waste of private insurance.Interesting point to make. While I'm not entirely sure that their point is bullet-proof, the inclusion of this point seems intended to stymie the arguments from the single-payer zealots that we should just get rid of all the insurance companies. Inasmuch as this article represents the zeitgeist of the Villagers in the Beltway at this time, I think it may fairly be inferred that the CW is that a market-based solution is preferable to a single-payer option. Fortunately.

Myth Four: Health-care reform is going to cost a bundle.I don't have a clever insight to offer here, but I'm still glad that Senator Wyden's plan is still part of the debate.

Myth Five: Americans aren't ready for a major overhaul of the health-care system.Don't know that this is currently a widely-accepted myth, but it's good to make the point. If it ever will be, the time is now, and the stars may be aligning.

WhiteCoat notes a 7% decline in patient volumes in his ED, which he attributes to the poor economy. My initial though was that a poor economy would do the opposite: more people would lose insurance and meaningful access to healthcare, so they would have to turn to Our Awesome Safety Net [tm] of the ER for their care. WhiteCoat does mention the migrant labor population as being in some way related, so I suppose that might make sense: as jobs dry up, workers leave. That got me wondering whether we might see something of the same effect in the Great, Damp Northwest. So I ran our most recent numbers, compared against last year:So I guess that'd be a "no." Volumes are up a few percent over last year, consistent with the year-over-year increases we've been seeing this decade. Not much evidence for any short-term effect over the last couple of months, either. I suppose that as the economy coninutes to crater, and we start to see the downstream effect of job losses, we may get a drop-off in volume. I kinda doubt it, though. We don't have a significant migrant population in our area, so we shouldn't see the demographic shifts Whitecoat describes. I do think the bad economy will further drive up our volumes.

The bad news for us will be that there will be fewer commercially insured patients, and more Medicaid and uninsured patients. This will drive our reimbursement down significantly, I suspect. I'm not complaing about that, mind you -- our losses will be a tiny fraction of the suffering of those who wind up unemployed, foreclosed or what-have-you in this impending recession.

Only time will tell, but I have a sinking feeling that this recession will be long and deep. I hope I'm wrong, or that Obama and his team are clever enough to figure out something to fix the economy. But the fundamentals are looking pretty grim just now, and I don't see any governmental intervention having much effect for quite a while.

Boy, this post took an unintended depresasing turn. Sorry about that. Wait, I know just what will cheer you all up: Puppies!

19 November 2008

I remember a bad hand-off once, long ago. It was the classic admitted patient, long forgotten two shifts after a bed had been ordered, but hanging out in the ER waiting for the assigned bed to be vacated and cleaned. It was a chest pain admission, a "low-risk rule-out," meaning that the patient was to get a blood tests to rule out a heart attack and then a stress test. Turns out the diagnosis was quite wrong: it was an aortic dissection, and when the patient crashed, there was chaos because nobody remembered why the patient was there and who was responsible for him.

In that case, there were other problems: the nurses in the ED had been quite content to ignore the patient while he slept. No vital signs were obtained, at one point the cardiac monitoring had been discontinued for the patient to go to the bathroom, and the schedule of blood tests designed to detect an evolving heart attack were not drawn.

The outcome was bad, and we as an organization learned a lot from it.

Doctor RW writes about this topic today, linking to an interesting article in Today's Hospitalist. RW's recommendation is good, but does not go far enough:

Hospitalist groups should meet with their emergency medicine colleagues regularly to discuss cases, offer feedback and improve professional relationships.

To be sure, this is necessary and I won't disagree with it. But the fact is this: if the patient is physically in your ED after "admission," they remain your responsibility, and as a department, you must have procedures in place to ensure the patient will continue to receive excellent care during the transition.

Key points which such procedures must address include:

There must be an ED physician who is the designated responsible provider and who is aware of the patient. This is pretty standard and is easily accomplished with most patient tracking system, be they simple grease boards or sophisticated EMRs.

Transfer of care to the hospitalist does not take place until the patient has either left the ED or until the hospitalist has physically seen the patient in the ED.

The ED doc must perform interval assessments of the "boarding" patients in the ED, regardless of whether the hospitalist has seen them. If they're in the ED, they're still your responsibility. Generally, stable patients don't take much attention, but sicker patients, ICU admits, etc will require this assessment. If nothing else, it can add to your critical care time!

Once the hospitalist has seen the "boarded" patient, they are the primary caregiver, and simple questions or non-urgent issues can be directed to them. But the ED doc must remain available for urgent issues and to keep tabs on the patient's condition.

Inpatient admitting orders should be written at the time the patient is designated as "admitted." The ED nursing staff need to follow these orders as if the patient were in their inpatient bed, especially if the patient will be boarding more than a couple of hours.

If you are in the enviable position of sending patients upstairs before the admitting doc has seen them, you need to write adequate holding orders.

For some reason, this last point has been controversial in EM. The AAEM, I think, particularly crusades against this practice. I cannot understand why. Sending patients upstairs to languish until the hospitalists see them is a clear extension of liability for the ER doc. Yeah, it would be great if all admits were seen within ten minutes of arrival to the floor, but that's not reality. There's a persistent idea that writing admitting or holding orders somehow increases the ER docs' liability and muddies the question of who bears responsibility for the inpatient.

My opinion is that by writing good holding orders, the ER docs improve patient care, help the hospitalists, and reduce everybody's risk. The key is that these orders do not need to be comprehensive, but they do need to be adequate. In my opinion, the minimum acceptable holding order set includes:

The name of the responsible admitting doc.

A clear statement that for problems, questions, or changes in condition, the admitting doc should be promptly notified.

A defined time during which your holding orders are valid (i.e. an expiration time for your orders, by which time the admitting doc needs to have seen the patient).

Any scheduled tests or treatments which will forseeably be needed before the patient may be seen (serial enzymes, nebs, pain meds, blood sugars, e.g.)

Parameters to notify the admitting doc (vitals, test results, etc)

When well done, this practice can improve patient care and safety and foster the sense of collaboration between the hospitalists and the ER docs. Standardization is your friend; we have a pre-printed "holding order" set which is very useful and help ensure nothing important is omitted. As hospital-based medicine is a team sport, it is also useful to have joint committees set up between the ER and hospitalist teams. Working together regularly outside of the clinical setting also helps foster a sense of collegiality, and to dispel the "us-vs-them" sentiment that is engendered in the trenches.

This is a pretty important topic. Change of shift is the most dangerous time in any ER, and the transfer of care is fraught with risk. It's curious, now that I think about it, that this has received so little attention in the evolving culture of patient safety and the Quality measures being developed. Look for this to gain prominence in coming years.

18 November 2008

I've never been much interested in playing the breathless speculation "Who's going to be Secretary of xxxxxxx," games that so consume the Beltway types. But for what it's worth, Obama could do worse than former Governor John Kitzhaber of Oregon for Secretary of Health and Human Services. He's an Emergency Physician who developed and implemented a universal health care plan in his state, and since leaving office has advocated tirelessly for national health care reform.

I've attended a few speaking engagements with Dr Kitzhaber, and have come away impressed at his knowledge of health policy and his pragmatic and value-driven approach to reform. He'd be a good guy to have on the team.

17 November 2008

Kevin linked to an interesting article in the Boston Globe. It has way too many words, and as usual when the media tries to write about health care economics, completely misses the point. In fact, the authors, bless them for trying, can't even bring themselves to ask the right questions. A brief summary:

Brigham & Women's Hospital, Mass General, and other well-known hospitals ("Partners HealthCare") get reimbursed 15-60% more than less-elite institutions in and near Boston.

The quality of care at all these institutions is comparable.

Partners HealthCare are extorting patients by leveraging their market power to demand higher compensation from commercial insurance companies.

That's it. The whole 5,000 word bowel movement, distilled in all its ineffable ignorance to under sixty words.

Now the first impenetrably stupid thing the authors do is begin with the assumption that compensation for services in medicine is linked to quality. I can understand their desire to believe this to be so, and I can understand their error, given the publicity given to the various quality initiatives and Medicare's P4P programs. But it is not so. Quality measurement is in its infancy and at this time the financial linkage of quality to compensation is something on the order of 2% of medicare revenues and a few small pilot programs by commercial payers. If the authors wished to write an editorial arguing that we should link quality to compensation on a grand scale, that would be a fair matter for debate. But they assumed their conclusion, and proceeded to lambaste the Partners health system without ever once considering the bigger picture.

In fact, I have to wonder if they even read their own article.

In context, readers need to understand that health care (especially the hospital business) is not a lucrative business. The typical hospital's profit margin is about 1.75%, and fluctuates wildly year to year in the throes of economic cycles and federal budgetary shortfalls. The pressure is ever downwards, from Medicare and Medicaid especially. Hospitals, especially those with significant charity care costs, must cost-shift, which is to say they must charge private patients more than the actual cost of their care in order to subsidize the care provided at a loss to the government-insured and uninsured patients.

Insurers, understandably, do not like this, and will fight tooth and nail to drive down the amount they will pay for their patients to be served at a given facility. Those that are able to negotiate favorable contract terms will do well. Those that cannot will wind up like this:

[T]he state's second-largest hospital chain, Caritas Christi, had to borrow money this year to pay for basics, like oxygen tanks.

This is, mind you, from the same article which strongly stated that Partners was making too much money, and that they were overcharging patients for sub-par services. (At least Partners hospitals have oxygen tanks, though! Hahaha.) The authors stated outright that the greed and lasciviousness of the Partners system was a key force in the explosion of premium costs for Massachusetts residents. Partners clearly should back off and charge reasonable rates, like the rest of Mass. hospitals. Say, how are they doing, anyway? Let's go to the same damn article:

Massachusetts hospitals are losing money. Many of them would be profitable if they had even a fraction of Partners' contract clout. Caritas Norwood Hospital, for instance, could erase the $242,347 deficit it reported through the third quarter of this fiscal year if the hospital were paid Partners rates for the babies it delivers.

I'm sorry, my irony gland is hurting. I'm not sure I read that right. So, if the other hospitals were able to get compensated for their services at the Partner's rates, they would be making money. Instead, the insurance companies underpay when they can get away with it, and all the rest of the hospitals are losing money. And Partners is the bad guy? What about the insurance companies who are conspiring to depress the prices paid to the hospitals? (To say nothing of the government which underpays everybody.)

So how much is Partners fleecing the Boston public for? Let's see:

Partners' favorable insurance contracts have helped the company to reap $1.7 billion in profits since 2004, reflecting a profit rate that is average compared with the nationally known hospitals the company considers its peers.

Average, huh? That doesn't sound too bad. But what's average? Well, according to the Fitch bond rating agency, Partners posted a 2.2% operating margin for 2006 (the 2006 Fitch average was 2.8%) with $132 million "profit" (which isn't actually a profit but can be re-invested into the organization). Fitch also expresses concern about:

"Partners' high Medicaid mix and increased charity care at certain facilities, the concentration of three large managed care organizations that control a significant 80% of the managed care payer market, the competitive Boston market, and future capital needs. Partners has incurred significant losses in Medicaid and uncompensated care, which has hindered overall profitability."

What I see here is a well-run institution which manages, despite a mission which includes charity care for indigent patients, to market itself effectively and sustain itself, and to renew and grow the organization. The victims in this scenario are the regional centers which manage to deliver excellent care (as measured by the rather crude statistical metrics) despite being undercapitalized and under-reimbursed by the insurance companies.

And what about those insurance companies, anyway? How did they figure into this piece of investigative journamalism? The Globe reports:

Private insurance data obtained by the Globe's Spotlight Team show that the Brigham, Mass. General, Children's Hospital, and a few others are, on average, paid about 15 percent to 60 percent more than their rivals by insurance companies such as Blue Cross Blue Shield of Massachusetts and Harvard Pilgrim Health Care. [Emphasis added]

Hmmmm. How do you think The Globe just happened to chance upon the very closely-guarded data cited here? What player would be in a position to know how much BCBS pays all the local hospitals? Let me think . . . waitaminit! It's BCBS! How else would The Globe happen to obtain the complete (or selected?) fee schedules for all the regional hospitals if it was not deliberately leaked to the media? And why would the insurance companies want to do this? Maybe they are sick of having to pay higher rates to Partners, and decided to leak embarrassing information to gullible journalists to make Partners look bad. Maybe it'll help BCBS in their next contract negotiation, and if not, at least it's a finger in the eye of their hated enemy.

Make no mistake, this bit of "investigative journalism" is nothing more than a hit job on Partners HealthCare by the insurance companies, abetted by the naivete of poorly-informed journalist-stenographers who eagerly gobbled up the data they were spoon-fed and happliy ran with the prefabricated narrative they were handed by Blue Cross Blue Shield, with some bonus snark thrown in by Partners' jealous competitors, and layered with a veneer of concern for quality of care.

And we wonder why the traditional media is losing credibility.

Disclosure: I have never set foot in Boston and have no relationship to or brief for the Partners system. My own facility is itself in a tense struggle with the local high-profile, better funded regional giant. I, however, do not blame them any more than I blame Microsoft for selling a lot of copies of Office. It's market economics. We are playing at a disadvantage and we will only prosper if we can run a leaner operation, deliver excellent care, and find our own leverage with private payers.

11 November 2008

A little background: Copass, trained in neurology, has been running the ER for thirty-some years. He has run his fiefdom with an iron fist and a cult of personality striking in large part for his antipathy towards the field of Emergency Medicine as a specialty. The University of Washington has become something of a local embarrassment, being the last of the top ten medical schools in the US (actually, the last of the top fifty!) not to have a training program in Emergency Medicine. Copass has sworn, apocraphally, that it will be over his dead body that there will be an EM program in "his" ER.

The consequence is that over the last twenty years, with regard to emergency care and training, UW has slowly slipped further and further behind other mainstream university medical centers. The political environment has been toxic, with even UW faculty members decrying the insitutional hostility towards EM. Matters came to a head a few years back when the ACGME decertified Harborview's EM training program, a move which resulted in the EM residency at Madigan pulling its residents from Harborview, citing "inadequate supervision," specifically a lack of supervision from trained Emergency Physicians. (Others have alleged that supervision at all in Harborview's ER is "nominal.") Madigan now sends its residents to Emanuel in Portland for their trauma training. Seattle, the 15th largest metro area in the US, does not have a dedicated training program in EM; most cities this size have two or three.

The University was, I think, highly embarrassed by the fiasco. Since that time, they have recruited for and hired a number of trained and certified Emergency Physicians. (Some of whom are good friends of mine.) The word on the street is that the UW is finally intent on starting a training program in EM, which would be a welcome and long overdue development. If Copass was encouraged to retire in order to remove one of the last remaining obstacles, it would be an ironic capstone on a career which has in some respects been dedicated to opposing the development of EM as a specialty.

Still, there's going to be yeoman's work to be done at Harborview. The insitutional bias against EM may run deep, and the faculty who take over the reins of the department will have their work cut out to establish control over the department and autonomy of their operations. I admire and respect those colleagues who have signed up to bring about the needed change. It's thankless work, fighting these turf battles. Most of the work to establish EM as an independent specialty was done in the '80s and '90s: it seems very weird and anachronistic to have to go back and revisit those battles. I will be cheering them on, and I look forward to a time not too far in the future when I may have the opportunity to work with UW residents, or to hire graduates from a local program.

I should stipulate here, that I have never worked at UW, did not train there, and have never met Copass. I do not doubt that he has been a dedicated physician and educator. If I have misstated his positions here, I will be only too happy to publicly apologize. However, his reputation is that of a divisive persona who has persisted in fighting one of the last bitter turf battles in the house of medicine. To the degree that is true, he will not be missed.

10 November 2008

The practice of medicine, as a business, is a challenging model. You have minimal control over your prices, no ability to negotiate with your biggest payers (the governmental ones, that is), and limited leverage to contract with commercial payers. In our specialty, you also know that a certain significant but unpredictable fraction of your patients will not be paying you at all, and you have to staff to an expected patient volume, but you have no real ability to control your volume. Compensation for services from all payers is perpetually squeezed downward, and given the narrow focus of our specialty, it is difficult to diversify the business model.

So, if you want to run a profitable and successful practice, you need to focus on the internal efficiencies to maximize your revenue. The universal inefficiency in EM practices is physician documentation; this inefficiency is, of course, also an opportunity to improve, and thereby increase your revenue. For most practices, 85% of revenue can be accounted for with only seven codes: 9928x and 9929x in coding jargon, commonly referred to as the Evaluation and Management (E/M) codes and Critical Care (CC). A lot of attention is paid to the E/M coding requirements, as they are onerous and failure to comply will absolutely sink your business. But Critical Care is often overlooked, and this underutilized code can provide a significant profit margin for your practice.

As you can see, one hour of Critical Care is worth about 25% more, per case, than a Level 5 E/M charge. Of course, your experience may vary depending on your payer mix, collection rate, and current coding levels, but optimizing your CC coding has the potential to add 2-5% to your total revenue. That may not sound like much, but those are totally "free" dollars -- there is no added cost to generate that additional revenue, so it goes directly to provider compensation. Depending on your practice's overhead, that may increase physician compensation by 3-9%.

So why don't Emergency Physicians routinely code for CC time? Well, many do, and the frequency with which this code is utilized in the ED has been steadily increasing:

(Source: BESS data, representing Medicare patients only.) Some of this increase, however, may be due to the increasing practice of "boarding" critical patients in the ER waiting for inpatient beds. Some may be due to the increasing age, complexity, and acuity of patients in the ER. But it is undeniable that Emergency Physicians are catching on to the value of appropriate utilization of the CC code.

Many challenges remain to widespread adoption of this code. Many EPs are just unaware of the value of this code and the opportunity it represents. Emergency Medicine residencies do a terrible job of educating their physicians in this area, which puts young physicians at risk of losing income as they get up to speed with the business of medicine. Additionally, many EPs are a bit jaded and undervalue their services, not recognizing when they have provided critical care.

Furthermore, CC is a unique code in that it requires a break in the routine documentation flow. Unlike almost every other procedural code used in the ER, for CC, the physician must explicitly and affirmatively ask for it. For every other code, the professional coder can infer from the record what was done and apply the appropriate codes, but CC requires that the EP remember to claim it, and document in a very specific manner what was done in order to compliantly receive credit for the service provided. Critical care requires that the doctor record the time spent, the "unbundled" associated procedures, and a defensible summary of the critical illness and interventions. While not difficult, these requirements are different from those for the other 90% of patients seen in the ED, and require the EP to approach the record in a different manner that they otherwise do.

So what is "Critical Care" anyway?The nice thing is that Medicare provided a very loose and vague definition, and left it to physicians to decide on a case by case basis. According to the most recent Medicare definition (PDF) : Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient’s condition. Critical care involves high complexity decision making to assess, manipulate, and support vital system functions(s) to treat single or multiple vital organ system failure and/or to prevent further life threatening deterioration of the patient’s condition.

There are a three key requirements which must be met for critical care:

Time.

Medical Necessity/Criticality.

Interventions.

Let's address these individually.

Time:This is a time-based code; the physician must document the total time spent in the care of this patient. The first 30-60 minutes will be billed as code 99291, and subsequent half hours will each be billed as a 99292. The time element is the most commonly missed. Frequently physicians will provide wonderful documentation of their critical care services, but failure to explicitly record the time spent will result in the case reverting to an E/M code. Coders are not allow to infer from the record how much critical care time the patient received.

The time requirement is cumulative, meaning it need not be continuous. So if the patient is in the Department for six hours, but you spent 90 minutes over this time frame devoted to the patient's care, you may bill for 90 minutes of critical care. This does includes time not at the bedside, and explicitly includes activities such as lab review, consultations, family decision-making, and documentation. You do not need to explicitly break down a line-item summary of the activities you engaged in.

A key requirement is that you must be "immediately available" to the patient during this time. For this reason, time spent off the unit cannot be included in CC time. This effectively means that providing prehospital control to EMS can not count towards the total time.

Criticality:This is the huge subjective element in CC today, and may represent the greatest opportunity (as well as the greatest risk) for your practice. CPT provides examples of critical care which are intended to represent the "mid-range" of CC services. However, CPT also provides examples of Level 5 E/M cases which appear to meet the definition of critical care as it is currently understood. For example, any patient who experiences acute respiratory or circulatory failure requiring ventilatory support or vasopressors is clearly critical. However, a patient with unstable angina requiring intravenous nitrates, beta blockers, and anticoagulants certainly also meets the definition. Or a patient with a GI bleed requiring fluids resuscitation and transfusion. For that matter, the current definition of sepsis/SIRS is quite broad, and patients with SIRS, even early SIRS, meet the broad definition of "high probability of deterioration."

The key here is to recognize that criticality extends far beyond the intubated patient to a wide variety of conditions.

Intervention:In order to fully justify the service you are claiming, it is necessary to have done something for the patient. That may include anything from heroic life-sustaining measures to very simple measures such as crystalloid fluid resuscitation, so long as the criticality requirements are met. The CPT definition clearly includes complex decision-making as meeting this requirement. It is, however, more justifiable when there is a tangible and clearly identifiable intervention was performed which can be said to have averted or treated the patient's actual or potential deterioration.

Documentation:What's not required for critical care is almost as important as what is required. The standard E/M components of HPI, ROS, Past/Family/Social History, etc are not required. While you omit them at your peril (from a medical liability point of view), these are not required elements of a critical care chart from a coding and billing perspective.

It is important to understand that a variety of procedures are included, or "bundled" into CC. These are: blood draws, peripheral IV placement, blood gas interpretation, NG placement, Pulse oximeter interpretation, ventilator management, transcutaneous pacing, and CXR interpretation. You may not bill separately for these items on a critical care patient. However, all other procedures still may be billed separately, including but not limited to: intubation, central line placement, EKG interpretation, cardioversion, tube thoracostomy, laceration repair, fracture care, lumbar puncture, etc etc etc. Be aware that CPR supervision is a separately billed service, and CPR time bust therefore be subtracted from your total Critical Care time. It is very important to explicitly note that the time you spent providing critical care services was "exclusive of all other separately billed services." Memorize that phrase and be certain to use it in every critical care dictation you do!

Compliance and Risk:As Medicare's RAC process turns its attention to professional billing, it is predictable that this will draw its attention and that audits will result, especially in light of the increase in the utilization in these codes. As the standards are somewhat loose, how to demonstrate compliance is on everybody's mind. The key is, I think, to set standards in advance and consistently apply them, and to document explicitly the nature of the patient's criticality. In almost every critical care case, I include the statement that I felt the patient was at high risk of "X" to make it very clear to the coder (and any auditor) why I felt the patient was critical. Auditors generally give a fair amount of latitude to the judgment of the provider, so long as you explain your thoughts.

Supporting evidence of criticality which is helpful to highlight in your documentation might include:

Obvious problems like respiratory failure or circulatory failure.

Any organ system which has acutely failed (or may fail).

Significantly abnormal vital signs.

Shock, even early shock.

Acidosis.

Need for interventions such as central venous access, thoracostomy, cardioversion/defibrillation, transfusion of blood products, or the "ACLS" suite of IV medications.

ICU admission may support the criticality of the patient, but is alone not sufficient, especially if the patient is admitted as an overflow patient, or as a chronic ventilator patient.

There is some debate regarding whether Critical Care may be justified based on the presentation alone, or whether an actual critical illness need be present. Consider, for example, a trauma patient whose injuries turn out to be non-life-threatening. Some claim that the patient, prospectively, was an unknown and had a high potential for deterioration. However, the guidelines state that "both the illness or injury and the treatment must meet the requirements." This requires that the patient has an actual illness/injury, not a potential one.

Conversely, there may be cases in which the patient is manifestly critically ill, but the EP does not actually provide direct treatment. For example, consider the stable patient who comes in with a cerebral hemorrhage. If all the EP does is order the CT and call the neurosurgeon, there was no critical care provided. If the patient required urgent blood pressure control, that would be different, but absent some intervention, Critical Care is not appropriate.

And there are some patients who are critical but do not meet the time requirements. In my institution, ST-Elevation MI's go very quickly to the cath lab, and are often in the ED for only fifteen or twenty minutes. While the illness is critical, and the intensity of service provided in that time is high, the time requirement is absolute, and these patients must be coded out as level 5's. (Using the "patient acuity" caveat for the ROS, of course.)

Frequently Asked Questions:Can you code Critical Care on a patient who is subsequently discharged home?Yes, but be cautious. A compliant chart would make it quite clear that the patient was indeed critical and that there was an intervention which changed the course of their illness. An auditor would likely be skeptical of CC on a discharged patient, so I would recommend that your documentation be bullet-proof in these events. The most common example I can think of would be an overdose requiring temporary airway management, and things of that sort.

Can Critical Care be billed as a shared service between physicians?No. If two physicians of the same specialty within the same group both provide 30+ minutes of critical care on the same day, the first must be billed as 99291, with subsequent increments of 99292 as appropriate. If each physician accounts for only 15 minutes of time, it may not be combined.

Can an ER physician bill for an E/M service and Critical Care on the same calendar date? Not for Medicare patients. CMS specifically prohibits this, for the ER E/M codes only. CPT guidelines will permit this, so long as the services provided are separately identifiable and discrete. Some commercial payers may recognize this, but it is fairly uncommon and often will be rejected by payers. If the patient presents prior to midnight and receives 30+ minutes of critical care both prior to and after midnight, two units of 99291 may be billed.

Can an attending bill for teaching time, or time spent by resident physicians?Teaching time may not count towards Critical Care. However, the attending may bill for time spent supervising the resident so long as the attending is physically in the room with thepatient while the services are being provided, and documents: "(1) the time the teaching physician spent providing critical care, (2) that the patient was critically ill during the time the teaching physician saw the patient, (3) what made the patient critically ill, and (4) the nature of the treatment and management provided by the teaching physician." The attending may reference the resident's documentation for details.

Can a PA or Nurse Practitioner bill Critical Care time?Yes, provided all the other guidelines are met. As with Physicians, this may not be billed as a shared service.

In summary, Critical Care is a valuable service which we provide to our patients, and it is correspondingly well-reimbursed. Most Emergency Department practices still do not utilize it as fully as is allowed, and optimizing your critical care coding can provide a valuable profit margin to your practice's bottom line. However, given the increasing attention to this code, future audits are all-but-certain, and it is essential to consider the compliance elements of this code and be certain that your documentation supports the value of the services you are providing to your patients.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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